MKSAP Questions of the Week

Infectious Disease Q86

A 57-year-old woman is hospitalized with a 1-month history of diminished concentration, memory, and judgment, with recent mental status fluctuations and gait disorder. Medical history is remarkable for hypertension. Medications are enalapril and hydrochlorothiazide. On physical examination, vital signs are normal. She is somnolent but responds to verbal commands. The neck is supple. Deep-tendon reflexes are increased in the upper extremities and decreased in the lower extremities. Movement of the extremities is associated with myoclonus. The remainder of the examination is normal. Complete blood count, comprehensive metabolic profile, thyroid studies, and vitamin B12 measurements are normal. Gram stain of cerebrospinal fluid is negative. Polymerase chain reaction of cerebrospinal fluid for herpes simplex virus is negative. Brain MRI shows abnormally increased T2 and FLAIR signal intensity in the putamen and head of the caudate.

Publish date: 07/23/2021

 
Hematology-Oncology Q20

A 28-year-old woman undergoes follow-up consultation regarding a pre-employment physical examination. She reports feeling well, with no recent illness. Medical history is notable for gastroesophageal reflux disease. Her only medication is omeprazole. She is Black. On physical examination, vital signs and other examination findings are normal. A peripheral blood smear shows decreased neutrophils, normal lymphocytes, normochromic erythrocytes, and normal platelets.

Publish date: 07/15/2021

 
General IM Q47

A 51-year-old woman is referred for evaluation. She has a 10-year history of chronic pain that she describes as head-to-toe aching, twisting, and sometimes burning that involves several large muscle groups. The pain is constant, and she rates the severity as a 6 on a 10-point scale. She is able to work despite the pain but is constantly fatigued. Her current regimen of oxycodone provides minimal relief. She has tried three other opioid medications as well as gabapentin and milnacipran, all of which provided only minimal improvement in her pain. Medical history is also significant for generalized anxiety disorder treated with sertraline. On physical examination, vital signs are normal. There is tenderness in multiple large muscle groups. The remainder of the physical examination is normal.

Publish date: 07/07/2021

 
Gastroenterology Q44

A 45-year-old man is evaluated for a 2-month history of a burning sensation starting in his stomach and radiating into his chest, usually occurring 4 to 5 times weekly. He says that he usually eats dinner late and then goes to sleep. He often wakes up with a sour taste in his mouth. He reports no dysphagia or unintentional weight loss. He takes no medication. On physical examination, vital signs are normal; BMI is 34. The remainder of the examination, including abdominal examination, is unremarkable.

Publish date: 06/30/2021

 
Endocrinology Q73

A 32-year-old man is evaluated for decreased libido and fatigue. His symptoms have increased over the last 6 months. His medical history is otherwise unremarkable, and he takes no medications. On physical examination, vital signs are normal. BMI is 26. He has gynecomastia. Visual field acuity testing and testicular examination are normal. Smell is intact.

Publish date: 06/24/2021

 
Dermatology Q29

A 27-year-old woman is evaluated in the office for generalized hair loss. She has not had any similar episodes previously. The patient is 3 months postpartum and does not take any medications. On physical examination, vital signs are normal. The scalp skin itself appears normal with no erythema, scale, or scarring. The hair shafts are normal as well. As the hair was combed through, several hairs fell out at the root. The remainder of the examination is unremarkable.

Publish date: 06/16/2021

 
Cardiology Q91

A 72-year-old man is evaluated for a 1-year history of bilateral lower extremity edema and abdominal distention. Eight years ago he had esophageal carcinoma treated with radiotherapy. Medical history is otherwise significant for hypertension, type 2 diabetes mellitus, and hypercholesterolemia. Medications are bumetanide, atorvastatin, metformin, and lisinopril. On physical examination, the patient is afebrile, blood pressure is 170/90 mm Hg, pulse rate is 90/min, and respiration rate is normal. Jugular venous distention is present to the angle of the mandible while seated, with prominent pulsations. Cardiac examination reveals an early diastolic sound at the apex. The liver is palpable 5 cm below the costal margin. The abdomen is distended with ascites. There is bilateral pitting edema to the level of the thighs. Pulmonary examination reveals no crackles. Laboratory studies are significant for a B-type natriuretic peptide level of 96 pg/mL (96 ng/L).

Publish date: 06/09/2021

 
Rheumatology Q43

A 67-year-old woman is evaluated for a 3-year history of severe rheumatoid arthritis. She had an inadequate response to methotrexate and low-dose prednisone. She responded well to the addition of infliximab, but eventually the drug lost effect and she required a change in biologic therapy. She has done well with tocilizumab and methotrexate over the past year. She notes several months of prominent fatigue. History is also significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. Current medications are methotrexate, folic acid, tocilizumab, basal insulin, lisinopril, metoprolol, atorvastatin, ibuprofen, and omeprazole. On physical examination, vital signs are normal. Joint examination reveals no swollen or tender joints. The remainder of the physical examination is normal.

Publish date: 06/02/2021

 
Pulmonary and Critical Care Medicine Q46

A 46-year-old man is evaluated for 6 months of exertional dyspnea, fatigue, and ankle edema. Recently he experienced near-syncope walking up two flights of stairs. He has no other medical problems and takes no medications. On physical examination, blood pressure is 106/70 mm Hg, pulse rate is 94/min, and respiration rate is 18/min. Oxygen saturation is 90% breathing ambient air. On cardiac examination, a prominent jugular venous a wave is present along with widened splitting of S2. Lung examination is unremarkable. A transthoracic echocardiogram demonstrates a normal size left ventricle with ejection fraction of 65% and right ventricular enlargement. The estimated pulmonary artery systolic pressure is 58 mm Hg. Spirometry, lung volumes, and ventilation-perfusion scan are unremarkable; DLCO is 42% of predicted. CT angiogram of the chest is negative for pulmonary embolism and interstitial lung disease. Right heart catheterization demonstrates a mean pulmonary arterial pressure of 36 mm Hg, with no change with inhaled nitric oxide. Pulmonary capillary wedge pressure is normal.

Publish date: 05/26/2021

 
Neurology Q63

A 76-year-old man is evaluated for recent worsening of balance. He has no dizziness or lightheadedness. The patient has an 8-year history of Parkinson disease treated with carbidopa-levodopa and entacapone. On physical examination, vital signs are normal; no orthostatic decrease in blood pressure is noted. The patient has masked facies, a resting tremor, and bradykinesia. Gait assessment reveals mild shuffling without freezing. Findings from cognitive, cerebellar, and sensory examinations are unremarkable.

Publish date: 05/20/2021

 
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